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PubMed2004

Is it influenza or anthrax? A decision analytic approach to the treatment of patients with influenza-like illnesses.

STUDY OBJECTIVE: We analyze the risks and benefits of alternative treatment strategies for non-septic-appearing febrile patients with influenza-like illnesses and possible exposure to anthrax. METHODS: We used a decision analytic model to evaluate 6 testing and treatment strategies in an emergency department. Patients were non-septic-appearing and had influenza-like illnesses but low likelihood of exposure to anthrax. The following interventions were used: (1) no empiric antibiotics; (2) blood culture and treatment only if the result was positive; (3) rapid testing for influenza and, for those who tested negative, treatment with 60 days of ciprofloxacin; (4) a two-test strategy in which all patients were first tested for influenza; those who tested negative had a blood culture test and were treated empirically with ciprofloxacin for 3 days while waiting for blood culture results; (5) culture test for all patients and treatment with ciprofloxacin for up to 3 days while waiting for blood culture results; and (6) treatment of all patients with ciprofloxacin empirically for 60 days. Main outcome measures were deaths, complications from anthrax, adverse events from ciprofloxacin, and ciprofloxacin patient-days. RESULTS: For nonzero probabilities of anthrax, patient mortality was always lowest in the strategies in which all patients were treated empirically for anthrax either for 60 days or for 3 days pending blood culture results. These strategies, however, were associated with more morbidity (more ciprofloxacin patient-days and more antibiotic adverse events) than were strategies without empiric treatment. The numbers of adverse events and antibiotic patient-days were reduced substantially with the two-test strategy, in which patients with influenza were identified early and not treated. In general, for probabilities of anthrax equaling or exceeding 2%, treating all patients empirically for 60 days was best, but for probabilities between 0.1% and 2%, the sensitivity of blood culture for anthrax determined the optimal strategy: when the sensitivity exceeded 95%, a short course of empiric ciprofloxacin until blood culture results became available was best, but for sensitivities below 95%, more aggressive empiric antibiotics use was warranted. The proportion of patients with influenza in the community affected the choice of strategy, so that seasonal variation exists. CONCLUSION: During influenza season, our findings support rapid testing for influenza, followed by empiric treatment for anthrax pending blood culture results for those who test negative for influenza. Our results help to highlight the importance of developing rapid and sensitive tests for anthrax and of developing improved surveillance and methods to calculate the previous probability of attacks.

Anthrax↗
PubMed2006

Nasal immunization with a dual antigen anthrax vaccine induced strong mucosal and systemic immune responses against toxins and bacilli.

Anthrax-vaccine-adsorbed (AVA), the only anthrax vaccine licensed in the U.S., suffers from many major drawbacks. Therefore, there is a need to develop new generation anthrax vaccines that can be easily administered and induce strong immune responses not only against the anthrax toxins, but also against the toxin-producing vegetative anthrax bacilli. In the present study, we evaluated the feasibility of inducing strong mucosal and systemic immune responses against both anthrax toxins and bacilli after nasal immunization using a synthetic double-stranded RNA (dsRNA), polyriboinosinic-polyribocytidylic acid (poly(I:C) or pI:C), as the adjuvant. We have shown that the capsular poly-gamma-D-glutamic acid (PGA) from bacillus was immunogenic when conjugated to a carrier protein and dosed intranasally to mice. We further demonstrated that nasal immunization with the PGA-carrier protein conjugate in combination with the anthrax protective antigen (PA) protein induced both anti-PGA and anti-PA immune responses in mouse sera and lung mucosal secretions. The anti-PA antibody (Ab) response was shown to have anthrax lethal toxin neutralization activity; and the anti-PGA Abs induced were able to activate complement and kill PGA-producing bacteria. These findings demonstrated that it is feasible to develop a novel dual-action nasal anthrax vaccine.

Adjuvants, Immunologic↗
PubMed2004

Immune responses to Bacillus anthracis protective antigen in patients with bioterrorism-related cutaneous or inhalation anthrax.

Anti-protective antigen (PA) immunoglobulin (Ig) G, toxin neutralization, and PA-specific IgG memory B cell responses were studied in patients with bioterrorism-related cutaneous or inhalation anthrax and in a patient with laboratory-acquired cutaneous anthrax. Responses were determined for >1 year after the onset of symptoms. Eleven days after the onset of symptoms (15 days after likely exposure), anti-PA IgG was detected in 16 of 17 patients with confirmed or suspected clinical anthrax who were tested. Anti-PA IgG remained detectable 8-16 months after the onset of symptoms in all 6 survivors of inhalation anthrax and in 7 of 11 survivors of cutaneous anthrax who were tested. Anti-PA IgG levels and serum toxin neutralizing activity were strongly associated (R2=0.83). PA-specific IgG memory B cells were detectable in all 6 survivors of inhalation anthrax but in only 2 of 7 patients with cutaneous anthrax who were tested. Anti-PA IgG is an important diagnostic marker of anthrax, a predictor of serum anti-toxin activity, and a marker of immunological memory against anthrax.

Anthrax↗
PubMed2001

Update: Investigation of bioterrorism-related anthrax and adverse events from antimicrobial prophylaxis.

CDC and state and local public health authorities continue to investigate cases of bioterrorism-related anthrax. As of November 7, a total of 22 cases of anthrax have been identified according to the CDC surveillance case definition; 10 were confirmed inhalational anthrax cases and 12 cases (seven confirmed and five suspected) were cutaneous anthrax (Table 1). The majority of cases have occurred in persons working at postal facilities in New Jersey (NJ) and the District of Columbia (DC) in which letters contaminated with anthrax were handled or processed using high-speed sorting machines, or at media companies in New York City (NYC) or Florida (FL) where letters, either confirmed or presumed to be contaminated with anthrax, were opened or handled. The probable exposures for a case of cutaneous anthrax in NJ and a case of inhalational anthrax in NYC remain unknown. Epidemiologic investigations of these cases and surveillance to detect new cases of bioterrorism-associated anthrax continue. This report updates the investigation of these cases and describes adverse events associated with antimicrobial prophylaxis.

Anthrax↗
PubMed2001

Update: Investigation of bioterrorism-related anthrax, 2001.

This report updates the investigation of bioterrorism-related anthrax and the provision of antimicrobial prophylaxis to exposed persons and highlights CDC assistance to other countries investigating cases of bioterrorism-related anthrax. Since November 7, 2001, CDC and state and local public health agencies have identified no new cases of bioterrorism-related anthrax. As of November 14, a total of 22 cases of anthrax has met the CDC case definition; 10 were confirmed inhalational anthrax, and 12 (seven confirmed and five suspected) were cutaneous anthrax. Investigation of a case of inhalational anthrax in a hospital stock room worker aged 61 years in New York City (NYC) found no evidence of anthrax contamination at the work site or home; the source of exposure is unknown. Environmental clean-up of contaminated facilities continues, and surveillance for newcases of bioterrorism-related anthrax is ongoing in Delaware (DE), District of Columbia (DC), Florida (FL), Maryland (MD), New Jersey (NJ), NYC, Pennsylvania (PA), Virginia (VA), and other states.

Anthrax↗
PubMed1998

The pathology of experimental anthrax in rabbits exposed by inhalation and subcutaneous inoculation.

OBJECTIVE: Although rhesus monkeys are considered to be an appropriate model for inhalational anthrax in humans, an alternative for vaccine and therapeutic efficacy studies is desirable. This study characterized the pathology of lethal anthrax in rabbits challenged by subcutaneous inoculation and aerosol exposure. MATERIALS AND METHODS: New Zealand white rabbits were exposed by subcutaneous inoculation or aerosol to lethal doses of Bacillus anthracis spores. RESULTS: The pathology of anthrax in rabbits exposed by either route was similar, with principal findings occurring in the spleen, lymph nodes, lungs, gastrointestinal tract, and adrenal glands. The cardinal changes were hemorrhage, edema, and necrosis, with bacilli and limited leukocytic infiltration. Features that depended on the route of exposure included mediastinitis in aerosol-exposed rabbits, a primary dermal lesion after subcutaneous inoculation, and differences in the pattern of lymph node involvement. Lesions observed in rabbits were comparable to those of inhalational anthrax in humans and rhesus monkeys. Noteworthy differences included the lack of leukocytic infiltration in brain and meningeal lesions, the relatively mild mediastinal lesions, and a lower incidence of anthrax-related pneumonia in rabbits compared with humans. These differences may be attributed to the greater susceptibility of rabbits to anthrax. Increased susceptibility is associated with both reduced leukocytic response to the bacilli and a more rapid progression to death, which further limits development of leukocytic infiltrates in response to the basic lesions of hemorrhage and necrosis. Primary pneumonic foci of inhalational anthrax, which may be influenced by preexisting pulmonary lesions in humans, were not observed in our rabbits, which were free of preexisting pulmonary disease. CONCLUSION: Anthrax in rabbits may provide a useful model for evaluating prophylaxis and therapy against inhalational anthrax in humans.

Administration, Inhalation↗
PubMed2005

Anthrax: a continuing concern in the era of bioterrorism.

Anthrax, a potentially fatal infection, is a virulent and highly contagious disease. It is caused by a gram-positive, toxigenic, spore-forming bacillus: Bacillus anthracis. For centuries, anthrax has caused disease in animals and, although uncommonly, in humans throughout the world. Descriptions of this naturally occurring disease begin in antiquity. Anthrax is primarily a disease of herbivores, which are infected by ingestion of spores from the soil. With the advent of modern microbiology, Pasteur developed the first successful anthrax vaccine in 1881. The incidence of the disease has continually decreased since the late 19th century, and animal vaccination programs drastically reduced the animal mortality from the disease. However, anthrax spores continue to be documented in soil samples from throughout the world. Research on anthrax as a biological weapon began more than 80 years ago, and today at least 17 nations are believed to have offensive biological weapons programs that include anthrax. Recent events in the USA have shown how society is affected by both hoax and real threats of anthrax bioweapons. This fourth article in the series on weapons of biowarfare/bioterrorism summarizes the historical background of anthrax as well as clinical and laboratory information useful for bioterrorism preparedness.

Journal Article↗
PubMed2006

Anthrax lethal toxin has direct and potent inhibitory effects on B cell proliferation and immunoglobulin production.

Protective host immune responses to anthrax infection in humans and animal models are characterized by the development of neutralizing Abs against the receptor-binding anthrax protective Ag (PA), which, together with the lethal factor (LF) protease, composes anthrax lethal toxin (LT). We now report that B cells, in turn, are targets for LT. Anthrax PA directly binds primary B cells, resulting in the LF-dependent cleavage of the MAPK kinases (MAPKKs) and disrupted signaling to downstream MAPK targets. Although not directly lethal to B cells, anthrax LT treatment causes severe B cell dysfunction, greatly reducing proliferative responses to IL-4-, anti-IgM-, and/or anti-CD40 stimulation. Moreover, B cells treated with anthrax LT in vitro or isolated from mice treated with anthrax LT in vivo have a markedly diminished capacity to proliferate and produce IgM in response to TLR-2 and TLR-4 ligands. The suppressive effects of anthrax LT on B cell function occur at picomolar concentrations in vitro and at sublethal doses in vivo. These results indicate that anthrax LT directly inhibits the function of B cells in vitro and in vivo, revealing a potential mechanism through which the pathogen could bypass protective immune responses.

Animals↗
PubMed2006

Nasal immunization with anthrax protective antigen protein adjuvanted with polyriboinosinic-polyribocytidylic acid induced strong mucosal and systemic immunities.

PURPOSE: The current anthrax vaccine adsorbed (AVA) was originally licensed for the prevention of cutaneous anthrax infection. It has many drawbacks, including the requirement for multiple injections and subsequent annual boosters. Thus, an easily administrable and efficacious anthrax vaccine is needed to prevent the most lethal form of anthrax infection, inhalation anthrax. We propose to develop a nasal anthrax vaccine using anthrax protective antigen (PA) protein as the antigen and synthetic double-stranded RNA in the form of polyriboinosinic-polyribocytidylic acid (pI:C) as an adjuvant. METHODS: Mice were nasally immunized with recombinant PA admixed with pI:C. The resulting PA-specific antibody responses and the lethal toxin neutralization activity were measured. Moreover, the effect of pI:C on dendritic cells (DCs) was evaluated both in vivo and in vitro. RESULTS: Mice nasally immunized with rPA adjuvanted with pI:C developed strong systemic and mucosal anti-PA responses with lethal toxin neutralization activity. These immune responses compared favorably to that induced by nasal immunization with rPA adjuvanted with cholera toxin. Poly(I:C) enhanced the proportion of DCs in local draining lymph nodes and stimulated DC maturation. CONCLUSIONS: This pI:C-adjuvanted rPA vaccine has the potential to be developed into an efficacious nasal anthrax vaccine.

Adjuvants, Immunologic↗
PubMed2006

Short-course postexposure antibiotic prophylaxis combined with vaccination protects against experimental inhalational anthrax.

Prevention of inhalational anthrax after Bacillus anthracis spore exposure requires a prolonged course of antibiotic prophylaxis. In response to the 2001 anthrax attack in the United States, approximately 10,000 people were offered 60 days of antibiotic prophylaxis to prevent inhalational anthrax, but adherence to this regimen was poor. We sought to determine whether a short course of antibiotic prophylaxis after exposure could protect non-human primates from a high-dose spore challenge if vaccination was combined with antibiotics. Two groups of 10 rhesus macaques were exposed to approximately 1,600 LD50 of spores by aerosol. Both groups were given ciprofloxacin by orogastric tube twice daily for 14 days, beginning 1-2 h after exposure. One group also received three doses of the licensed human anthrax vaccine (anthrax vaccine adsorbed) after exposure. In the ciprofloxacin-only group, four of nine monkeys (44%) survived the challenge. In contrast, all 10 monkeys that received 14 days of antibiotic plus anthrax vaccine adsorbed survived (P = 0.011). Thus postexposure vaccination enhanced the protection afforded by 14 days of antibiotic prophylaxis alone and completely protected animals against inhalational anthrax. These data provide evidence that postexposure vaccination can shorten the duration of antibiotic prophylaxis required to protect against inhalational anthrax and may impact public health management of a bioterrorism event.

Administration, Inhalation↗
PubMed1999

Experiences with vaccination and epidemiological investigations on an anthrax outbreak in Australia in 1997.

Between January and February 1997, there was a severe outbreak of anthrax on 83 properties in north-central Victoria, Australia. Vaccination was used as a major tool to control the outbreak by establishing a vaccination buffer zone 30 km by 20 km. In all, 78, 649 cattle in 457 herds were vaccinated in a three week program. In the face of the outbreak, there was a delay before vaccination was able to stop deaths. In the 10 days following vaccination 144 cases of confirmed anthrax occurred and 38 cases occurred more than 10 days after vaccination. When all cattle on at-risk properties were revaccinated in October and early November 1997, there were only two confirmed cases of anthrax in vaccinated seven and nine month old calves in the following anthrax season. Investigations into the epidemiology of the outbreak were unable to establish a single major association for the spread of the disease by flies, biting insects, carrion scavengers, wind, manufactured feed, milk factory tanker routes, veterinary visits, animal treatments, movements of personnel between farms or burning of carcases. The weather conditions in the outbreak area were part of a long dry spell with periods of high daily and night temperatures, continuing high humidity over the period and higher than normal soil temperatures. It is possible that extensive earth works in the district involving irrigated pasture renovation and water channel and drainage renovation could have disturbed old anthrax graves. It is postulated that these works released spores that were dispersed in the preceding wet winter across poorly drained areas that formed the axis for the outbreak. The earth moving renovations establishing irrigation in the area were conducted in the late 1890s, and before the occurrence of anthrax outbreaks were recorded. The axis of the outbreak was the major stock route for cattle and sheep moving from southern Victoria to northern Victoria and southern New South Wales, and undoubtedly there would have been extensive anthrax outbreaks before vaccine became available in the 1890s. In respect of other outbreaks, the events in Victoria most resembled outbreaks of anthrax recorded in the United States of America in the 1950s, 1960s and 1970s.

Animals↗
PubMed2001

Detection of anthrax spores in endemic regions of northern Canada.

AIMS: To determine the level of anthrax spore contamination in endemic regions of northern Canada between outbreaks. METHODS AND RESULTS: Bacterial endospores were extracted from specimens via flotation and cultured on selective PLET medium. Of 588 environmental specimens collected, 11 (1.9%) contained viable anthrax spores. CONCLUSION: High environmental concentrations of anthrax spores in northern Canada appear limited to scavenger faeces and anthrax carcass sites. Burial and cremation appear equally effective at removing anthrax spores from the immediate environment, though cremation may be improved by re-burning cremation sites containing unburned animal hair. SIGNIFICANCE AND IMPACT OF THE STUDY: This study describes an effective anthrax spore detection system. It provides the first bacteriological evidence that mammalian scavengers can disseminate anthrax spores in northern Canada, and its results may be compared with future environmental studies of untreated anthrax carcass sites to help improve government response plans.

Animals↗
PubMed2003

Figs--the earliest known ancient drug for cutaneous anthrax.

BACKGROUND: Anthrax is an often fatal bacterial infection, occurring in cutaneous, inhalational, gastrointestinal, and meningeal forms. Evaluation of anthrax treatment from ancient history may help healthcare providers to handle this serious disease more efficiently. OBJECTIVE: To evaluate the biblical descriptions of anthrax, focusing on its therapy in ancient times. STUDY SELECTION: All biblical texts associated with anthrax were examined and passages relating to this disease were studied closely. DATA SYNTHESIS: Biblical passages such as: "Take a cluster of figs. And they took and laid it on the boil [anthrax], and he recovered," and "Let them take a cluster of figs, and lay it upon the boil [anthrax], and he shall recover," convincingly indicate that figs have healing properties in cutaneous anthrax lesions. CONCLUSIONS: On the basis of this study, the National Institutes of Health together with the pharmaceutical industry may consider to work on isolation of compounds from fig plants to develop products against cutaneous and possibly other forms of anthrax once screening tests are completed.

Animals↗
PubMed2002

Anthrax of the gastrointestinal tract.

When swallowed, anthrax spores may cause lesions from the oral cavity to the cecum. Gastrointestinal anthrax is greatly underreported in rural disease-endemic areas of the world. The apparent paucity of this form of anthrax reflects the lack of facilities able to make the diagnosis in these areas. The spectrum of disease, ranging from subclinical infection to death, has not been fully recognized. In some community-based studies, cases of gastrointestinal anthrax outnumbered those of cutaneous anthrax. The oropharyngeal variant, in particular, is unfamiliar to most physicians. The clinical features of oropharyngeal anthrax include fever and toxemia, inflammatory lesion(s) in the oral cavity or oropharynx, enlargement of cervical lymph nodes associated with edema of the soft tissue of the cervical area, and a high case-fatality rate. Awareness of gastrointestinal anthrax in a differential diagnosis remains important in anthrax-endemic areas but now also in settings of possible bioterrorism.

Anthrax↗
PubMed2006

Systematic review: a century of inhalational anthrax cases from 1900 to 2005.

BACKGROUND: Mortality from inhalational anthrax during the 2001 U.S. attack was substantially lower than that reported historically. PURPOSE: To systematically review all published inhalational anthrax case reports to evaluate the predictors of disease progression and mortality. DATA SOURCES: MEDLINE (1966-2005), 14 selected journal indexes (1900-1966), and bibliographies of all retrieved articles. STUDY SELECTION: Case reports (in any language) between 1900 and 2005 that met predefined criteria. DATA EXTRACTION: Two authors (1 author for non-English-language reports) independently abstracted patient data. DATA SYNTHESIS: The authors found 106 reports of 82 cases of inhalational anthrax. Mortality was statistically significantly lower for patients receiving antibiotics or anthrax antiserum during the prodromal phase of disease, multidrug antibiotic regimens, or pleural fluid drainage. Patients in the 2001 U.S. attack were less likely to die than historical anthrax case-patients (45% vs. 92%; P < 0.001) and were more likely to receive antibiotics during the prodromal phase (64% vs. 13%; P < 0.001), multidrug regimens (91% vs. 50%; P = 0.027), or pleural fluid drainage (73% vs. 11%; P < 0.001). Patients who progressed to the fulminant phase had a mortality rate of 97% (regardless of the treatment they received), and all patients with anthrax meningoencephalitis died. LIMITATIONS: This was a retrospective case review of previously published heterogeneous reports. CONCLUSIONS: Despite advances in supportive care, fulminant-phase inhalational anthrax is usually fatal. Initiation of antibiotic or anthrax antiserum therapy during the prodromal phase is associated with markedly improved survival, although other aspects of care, differences in clinical circumstances, or unreported factors may contribute to this observed reduction in mortality. Efforts to improve early diagnosis and timely initiation of appropriate antibiotics are critical to reducing mortality.

Anthrax↗
PubMed2006

[Anthrax in Georgia: epidemiological situation and prognosis].

Anthrax, as an especially dangerous infection, needs permanent control from specialised institutions. The investigations became more important since the attempts to use Bacillus anthracis as the bioterrorism warfare. The issue is more acute for countries where the cases of anthrax are often registered. Cases of anthrax are registered whole around the territory of Georgia (69 regions). Analysis of morbidity during 1980-1989, 1990-1995 and 1996-2004 years showed the trend of increase of frequency of anthrax human cases. The territories where cases of anthrax are registered every year during last 10 years were established. Regions and towns of Georgia were ranged according to the frequency of anthrax cases. Physical -- geographical data and economic characteristics of regions with active hot beds of anthrax are presented. Some of isolates at the National Center for Disease Control and Medical Statistics (NCDC) of Georgia were investigated by molecular -- biological methods. Need for establishing and implementation of complex plan of measures for anthrax prevention is settled.

Anthrax↗
PubMed1994

Ecology and epidemiology of anthrax in the Etosha National Park, Namibia.

Analysis of mortality records has revealed distinct patterns in the incidence of anthrax in elephant and plains ungulates. The seasonal peak among the former is in November at the end of the dry season, while among the latter it occurs in March towards the end of the rainy season. Among elephants, there has been a notable spread of the disease to the west of the Park. Age and sex analyses indicate that, except for zebra, proportionally greater numbers of adult males die of anthrax among the species predominantly affected; however, zebra carcases are difficult to sex. In a study to identify possible environmental sources of infection, B. anthracis was detected in 3.3% of 92 water and 3.0% of 230 soil samples collected at different times of the year from 23 sites not associated with known cases of anthrax. Slight seasonal differences were noted with 5.7% positives occurring in the cold-dry period (May to August), 3.5% in the hot-dry season (September to December) and 1.4% in the hot-wet season (January to April). Higher rates (26.0% of 73 samples) were found in water from waterholes in the western part of the Park at the time of an outbreak in elephants. The possible importance of scavenger faeces was confirmed with > 50% of vulture, jackal and hyaena faeces collected from the vicinity of confirmed anthrax carcases yielding B. anthracis, sometimes in substantial numbers, while no spores were found in faeces not associated with known anthrax carcases. Despite terminal B. anthracis levels of usually > 10(7) cfu/milliliters in the blood of animals dying of anthrax, spore levels in soil contaminated by such blood at sites of anthrax carcases ranged from undetectable to a few tens of thousands. The rapid loss of viability in soil and water of anthrax bacilli was monitored experimentally and the importance of soil type demonstrated. Survival and extent of sporulation of the bacilli in water were shown to be dependent on the rate at which the blood was diluted out. Other relevant parameters examined were background flora, pH and sunlight.

Animals↗
PubMed2003

The history of anthrax.

Anthrax, a potentially fatal infection, is a virulent and highly contagious disease. Descriptions of this disease begin in antiquity, with the best ancient account being by the Roman poet Virgil. During the 19th century, anthrax was the infection involved in several important medical developments. It served as the prototype for Koch's postulates regarding the causation of infectious disease. The first vaccine containing attenuated live organisms was Louis Pasteur's veterinary anthrax vaccine. In the 1900s, human inhalation anthrax occurred sporadically in the United States among textile and tanning workers, but the incidence of the illness had declined dramatically. An outbreak of inhalation anthrax occurred in Sverdlovsk near a Soviet military microbiology facility in 1979. This epidemic represented the largest documented outbreak of human inhalation anthrax in history. In October and November 2001, 22 cases of confirmed or suspected inhalation and cutaneous anthrax were reported associated with the intentional release of the organism in the United States. An additional case of cutaneous disease occurred in March of 2002.

Animals↗